Healthcare Provider Details

I. General information

NPI: 1588913834
Provider Name (Legal Business Name): EAST TEXAS MEDICAL CENTER TYLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S BECKHAM AVE
TYLER TX
75701-1908
US

IV. Provider business mailing address

1000 S BECKHAM AVE
TYLER TX
75701-1908
US

V. Phone/Fax

Practice location:
  • Phone: 903-597-0351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number678245
License Number StateTX

VIII. Authorized Official

Name: CHRISTI DICKSON
Title or Position: EXECUTIVE SECRETARY/CREDENTIALING
Credential:
Phone: 903-596-3555